Patient COVID-19 Safety Screening Form

Personal Information

COVID-19 Symptoms

Have you experienced any of the following symptoms today or yesterday?

  • Cough
  • Sore Throat
  • Muscle Pain
  • Headache
  • Diarrhea
  • Shortness of Breath
  • Difficulty Breathing
  • Weak or Fatigued
  • Loss of Taste
  • Loss of Smell
  • Runny Nose
  • Nasal Congestion
  • Itchy Toes
  • Itchy Fingers

COVID-19 Testing & Diagnosis

Have you been diagnosed with COVID-19 in the preceding 10 days?

Do you live in the same household with or have you had close contact with someone who was diagnosed with COVID-19 or tested positive for the virus in the last 14 days?

Have you had a COVID-19 test in the past 7 days?

Sign & Date